Download Multivalvular disease.

Assessing function by echocardiography
in valvular heart disease
Multivalvular disease
Arturo Evangelista
DECLARATION OF CONFLICT OF
INTEREST
 None
Multivalvular disease
•
Multivalvular heart disease is not uncommon,
EHS > 15% of valve surgery.
•
Data on multivalve disease is scarce because of a
large number of possible combinations. Many areas
are not covered by the Guidelines.
•
Difficulties:
Exact quantification of different valve lesions.
Overlap in surgical indications.
Multivavular Disease
Quantification of Severity
• Doppler-echocardiographic methods have
been validated in single valve disease but
not in multivalve disease.
• Interactions between different valve lesions.
• Methods that depend less on loading
conditions are preferred, such as direct
planimetry of the stenotic valves.
Causes of multivalve heart disease
•
•
•
•
Rheumatic heart disease
Infective endocarditis
Degenerative valve calcification
Cardiac remodelling/dilatation (functional)
•
•
Adverse effects of treatment thoracic/mediastinal
radiation therapy
Adverse drug effects (ergot-derived agonists, anorectic
agents)
End-stage renal disease on haemodialysis
•
•
Carcinoid heart disease
Connective tissue disorders (Marfan syndrome, etc)
•
I- Aortic Stenosis and Mitral Regurgitation
Pathophysiology of interaction
between AS and MR
Aortic Stenosis and Mitral Regurgitation
•
With severe MR, transaortic flow rate may be low
resulting in a low gradient even when severe AS is
present; valve area calculations remain accurate.
•
Attention: Valve calcification, LV size, LV hypertrophy,
LA size, PAP.
•
Careful evaluation of MR mechanism is crucial for the
decision of whether also to operate on the mitral valve.
Severe Mitral Regurgitation and Aortic Stenosis
Mitral Regurgitation in Aortic Stenosis
•
MR often coexist with severe AS.
•
Careful echo examination is needed to obtain an etiologic
diagnosis of the mitral disease and grading the severity
of the MR.
•
When both valve lesions are severe surgery is
recommended for both lesions. If mitral lesion is feasible
mitral valve repair + AVR is recommended.
•
When MR is moderate or functional a conservative
approach to concomitant aortic surgery should be
considered.
Management of Mitral Regurgitation in
severe Aortic Stenosis.
II- Mitral Stenosis and Aortic Stenosis
•
The main aetiology is rheumatic heart disease.
•
Difficulty in quantification: a low-flow, low-gradient
situation may occur in both valves.
•
Emphasize “area assessment” in both stenosis.
•
Risk. Failure to recognise significant AS in PMV:
sudden haemodynamic changes in a previously
protected LV may lead to pulmonary oedema.
Mitral Stenosis and Aortic Stenosis
-
In severe MS and
non-severe AS, PMV
should be considered.
-
Main difficulty is to
assess AS severity:
low flow-low gradient
and atrial fibrillation.
III- Mitral Stenosis and Aortic Regurgitation
•
The association MS and AR is common. Approximately 10% of
patients with MS also have significant rheumatic AR.
•
The pressure half-time across
the mitral valve may be shortened,
leading to underestimated MS severity.
•
MS and AR generate opposite loading conditions.
Hyperdynamic contractility and LV enlargement may be less evident.
Mitral Stenosis with Aortic Regurgitation
IV- Mitral and Aortic Regurgitation
•
The association of MR and AR may be caused by rheumatic
heart disease, prolapse of AO - MI valves, (Marfan, aortic
ectasia). About 17% of patients who undergo surgery for
myxomatous aortic valve require surgical correction of
mitral regurgitation.
•
The combination of mitral and aortic valve regurgitation
produces severe volume overload of the left ventricle.
•
The reduction of ejection impedance allows the ventricle to
empty further, reducing ventricular wall tension with a
resultant increase of EF and in the velocity of LV
shortening. Therefore, EF may be a misleading parameter
for evaluating LV contractilily.
Aortic Regurgitation and Mitral Regurgitation
Large and Hyperdynamic LV
V- Tricuspid Regurgitation
•
Secondary TR is by far
more common than primary
causes, occuring mainly
from pressure overload
(PAH) provoking annular
dilatation and RV
enlargement.
•
TR is associated with poor
outcome and predicts poor
survival, heart failure and
reduced functional capacity.
Mild MS postcomisurotomy 22 y ago, mild AR,
severe TR
46mm
V- Tricuspid Regurgitation
ESC favours tricuspid surgery as a class IIa indiction in patients with
moderate secondary TR with a dilated annulus > 40 mm or 21 mm/m2
Severe MS+Moderate AR+Severe TR+ PAH
40 mm
120 mm Hg
9 months after PMV
1.6 cm2
1.3 cm2
47mm Hg
Diagnostic caveats in multivalve lesions
Indications for concomitant valve surgery in
patients undergoing surgery on another valve
Severe AS
Class I
Moderate AS
Class IIa
Severe AR
Class I
Severe TR
Class I
Moderate organic TR or
secondary TR with annulus > 40 mm
Class IIa
Indications for concomitant valve surgery in
patients undergoing surgery on another valve
• Severe MS and moderate aortic valve disease, If score < 10, PMV can be
performed.
• Severe MS combined with severe aortic valve disease,
surgery is preferable.
• MR with severe aortic valve disease: Severity and valve morphology
Moderate-severe MR with abnormal morphology : AVR+ MVR/ repair
Non-severe MR and normal valvular morphology: MR may improve
greatly after isolated AVR. (Intraoperative TEE and visual inspection).
Mitral prosthesis 5 y ago,
severe TR, severe AS.
53 mm Hg
Mean Gr: 46 mm Hg; AVA: 0.8 cm2
To distinguish the ripe from the
non deteriorated.
The challenge :
To define which will deteriorate soon
and to manage this information correctly
Conclusions
•Multivalvular disease is not infrequent. Various
combinations of valve lesions may be present and
data poverty does not allow the proposal of a clear
standarization.
•A careful quantification considering possible
pitfalls and a comprehensive assessment of the
consequences of the valve lesions is advisable
•Surgical indication should take into account the
interaction between different valve lesions, their
natural history, the risk of combined valve surgery
and the likelihood of future reoperation